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Improving Antibiotic Selection: A Systematic Review and Quantitative Analysis of Quality Improvement Strategies

Steinman, Michael A. MD*†; Ranji, Sumant R. MD; Shojania, Kaveh G. MD‡§; Gonzales, Ralph MD, MSPH†¶

doi: 10.1097/01.mlr.0000215846.25591.22
Original Article

Objective: We sought to assess which interventions are most effective at improving the prescribing of recommended antibiotics for acute outpatient infections.

Design and Methods: We undertook a systematic review with quantitative analysis of the Cochrane Registry Effective Practice and Organization of Care (EPOC) database, supplemented by MEDLINE and hand-searches. Inclusion criteria included clinical trials with contemporaneous or strict historical controls that reported data on antibiotic selection in acute outpatient infections. The effect size of studies with different intervention types were compared using nonparametric statistics. To maximize comparability between studies, quantitative analysis was restricted to studies that reported absolute changes in the amount of or percent compliance with recommended antibiotic prescribing.

Results: Twenty-six studies reporting 33 trials met inclusion criteria. Most interventions used clinician education alone or in combination with audit and feedback. Among the 22 comparisons amenable to quantitative analysis, recommended antibiotic prescribing improved by a median of 10.6% (interquartile range [IQR] 3.4–18.2%). Trials evaluating clinician education alone reported larger effects than interventions combining clinician education with audit and feedback (median effect size 13.9% [IQR 8.6–21.6%] vs. 3.4% [IQR 1.8–9.7%], P = 0.03). This result was confounded by trial sample size, as trials having a smaller number of participating clinicians reported larger effects and were more likely to use clinician education alone. Active forms of education, sustained interventions, and other features traditionally associated with successful quality improvement interventions were not associated with effect size and showed no evidence of confounding the association between clinician education-only strategies and outcome.

Conclusions: Multidimensional interventions using audit and feedback to improve antibiotic selection were less effective than interventions using clinician education alone. Although confounding may partially account for this finding, our results suggest that enhancing the intensity of a focused intervention may be preferable to a less intense, multidimensional approach.

Supplemental Digital Content is Available in the Text.

From the *Division of Geriatrics, San Francisco VA Medical Center; †Department of Medicine and ¶Division of General Internal Medicine, University of California—San Francisco; ‡University of Ottawa; and §Clinical Epidemiology Program, Ottawa Health Research Institute, Canada.

This article is based on research conducted by the Stanford-UCSF Evidence-Based Practice Center under contract to the Agency for Healthcare Research and Quality (Contract No.290-02-0017), Rockville, MD. This research was also supported in part by the Department of Veterans Affairs, and by a VA HSR&D Research Career Development Award (Dr. Steinman), and by a Canada Research Chair (Dr. Shojania). The authors are responsible for the contents of this article, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the US Department of Health and Human Services or the Department of Veterans Affairs. Dr. Gonzales has received unrestricted educational grant support ($10,000) from Abbott Laboratories, Inc., to pay for patient educational materials on appropriate antibiotic use. In research related to studies of C-reactive protein levels in adults with community-acquired pneumonia, Dr. Gonzales has served as a consultant to Abbott Laboratories, Inc, and has received an unrestricted educational grant ($10,000) from Axis-Shield, Inc. (Norway) to pay for chest radiography studies. Dr. Gonzales has served as an expert witness regarding the appropriate use of antibiotics, but not on the subject of quality improvement interventions to improve antibiotic use.

Reprints: Michael Steinman, MD, Department of Medicine, University of California—San Francisco, 4150 Clement St., Box 181G, San Francisco, CA 94121. E-mail:

© 2006 Lippincott Williams & Wilkins, Inc.